Polypharmacy: The dangers of mixing too many medications

TRANSCRIPT

Dr Maryanne DemasiNowadays there's a pill for just about everything. And it seems the older you are, the more you take. Up to 40 per cent of elderly people take five or more medications every day.

NARRATIONIt's a phenomenon known as "polypharmacy", where patients are on five or more medications, some of which are doing more harm than good.

Prof David Le CouteurIt's just that our psychology and our culture prefers to give medications rather than to withdraw them.

NARRATIONWhether they are prescribed or complementary medicines Australians consume more than 40 million pills each day.

Paul SinclairPatients may be accessing consultations from a number of different doctors and then seeking medications from a number of different community pharmacies.

Assoc Prof Sarah HilmerThere's no one person to overlook all of those drugs together and that's when people really run into trouble.

NARRATIONIn fact each year over 140,000 Australians are hospitalised because of problems with their medicines.

Prof David Le CouteurAdverse drug reactions are probably the fourth or fifth greatest killer after heart disease, cancer and stroke.

NARRATIONAnd the bad news is that with our ageing population the problem is getting worse. The older you are, the more health problems you have and the more specialists you see. Then you wind up on multiple medications putting you at risk of dangerous drug interactions.

Prof David Le CouteurMost commonly we see confusion and delirium, falls, and injury as a result of falls, and general symptoms like weakness and nausea.

NARRATIONJack McEnally was admitted to hospital after he fell and broke his hip.

Prof David Le CouteurAnd how's your walking been going?

Jack McEnallyAh, slowly.

NARRATIONHis medical records show he is on 19 different medications.

Jack McEnallyI felt a headache coming across here and then I felt some nausea.

Prof David Le CouteurCould I see you walk? Would you be able to take one or two steps for me do you think?

NARRATIONProfessor Le Couteur is now trying to work out which of Jack's medications are causing him problems.

Carmel McEnallySome of his heart tablets were interfering with the diabetic tablets so they're trying a different tablet and seeing if one doesn't interact with the other. They'll give us a list when we're ready to leave hospital of what he will be taking once he goes home.

NARRATIONAcross the ward, Mrs Meldrum has just been admitted. She's also on a cocktail of drugs.

Joan MeldrumI don't know exactly but I would say around 25 to 30.

Dr Maryanne DemasiWow, that's almost a meal!

Joan MeldrumI take arthro-aid for joints, a pill for heart and fluid... I have two that look at the reflux... the chest pain, angina... one that looks after my bladder... and the mood swing I do need because...

Dr Maryanne DemasiAnd the list goes on.

Joan MeldrumAnd the list goes on, yes. It goes on and on.

Prof David Le CouteurOur typical patient is on between five or 10 medications and I would say without exception, there are drug interactions in all of these patients. The common ones we would see would be interactions between drugs that cause bleeding, so these are the various drugs that are used to treat heart disease, and drugs that lower blood pressure, and drugs that act on the brain, so sedative drugs and anticholinergic drugs.

NARRATIONAdding to the problem are complementary medicines.

Prof David Le CouteurHigh doses of vitamin E are used to delay ageing but in fact increases bleeding so it can interact with other drugs used to treat heart disease and increase mortality. Ginko biloba is used by some people to try and help with their cognitive impairment and that also will interact with anti-platelet drugs and anticoagulants. St John's Wort is typically taken by people who have problems with depression and it will interact with the anti-depression, anti-depressive drugs that people are taking.

Assoc Prof Sarah HilmerIf you don't know someone is taking something you can't even begin to tell them that, hey, the reason you've got that dizziness when you stand up is probably because you're taking that extra medicine.

Prof David Le CouteurClinical trials without exception exclude people on polypharmacy. So we just don't know whether treating hypertension in someone who is already being treated with depression and osteoarthritis is of benefit.

NARRATIONThe other oversights in clinical trials are that drugs are always tested on young healthy volunteers, and only for short periods of time.

Prof David Le CouteurClinical trials do not include much older people, so people in their 80s and beyond, and the long term use of these medications is associated with adverse drug reactions that we just weren't aware of when the drugs came on to the market.

NARRATIONMrs Thorburn came to hospital a few days ago feeling unwell. She was on five medications.

Agnes ThorburnI was vomiting and very, very sick and he seemed to think that it was the tablets.

NARRATIONOver the last week, her doctor has been slowly reducing her medications.

Dr Maryanne DemasiHow do you feel?

Agnes ThorburnWell, I feel terrific...

NARRATIONMrs Meldrum often asks her doctor to reduce her medications.

Joan MeldrumOne doctor told me that he would take as many as I liked as long as I took the blame if I dropped dead, he said because who knows which ones are keeping you alive, and at 86 I don't want to drop dead.

Prof David Le CouteurThere’s a fear of litigation. So doctors are concerned that if they don't prescribe medications they will be sued for inappropriate withholding of medications.

NARRATIONNew research has developed a tool to help doctors work out which drugs are causing problems. It's called the Drug Burden Index.

Assoc Prof Sarah HilmerIt looks at a person's total exposure to high risk drugs in terms of how many of those high risk drugs they're on and also what dose they're on. Here we've got an example of one patient. We note down what medicines they're on, we look at the dose they're on and then we work out the drug burden index.

Dr Maryanne DemasiSo what does a total of one mean?

Assoc Prof Sarah HilmerYou could say that these two drugs that she's on are slowing her down as much as having depression, plus heart disease, plus lung disease.

Dr Maryanne DemasiSo ideally you'd like to take the patient off these drugs?

Assoc Prof Sarah HilmerYou would, yes you would aim to get this person's drug burden index down to zero.

NARRATIONBut in many cases patients will have to stay on certain drugs, so substituting one for another will help to at least reduce the patient's score. Another way to tackle the problem is to focus on pharmacies, where the drugs are dispensed. One idea is to give pharmacists electronic access to a patient's full drug history.

Paul SinclairElectronic health records will have a massive impact on polypharmacy by allowing both the doctor who is prescribing the medication and the pharmacist who is dispensing it to view that patient's entire health and prescription record if the patient elects that to be so.

NARRATIONIn the meantime there's a government program available called the Home Medicines Review. This enables you to have a pharmacist come to your home and conduct a comprehensive review of all your medications.

Assoc Prof Sarah HilmerAnyone can access it, it's a Medicare-funded commonwealth program. If you talk to your GP about it they can organise it, or often your GP will actually initiate organising it, and most community pharmacies will have a pharmacist who is accredited to do home medicines reviews and will come out and will do that for you.

Paul SinclairWe'd certainly encourage customers or patients to establish a relationship with a community pharmacy so that at any time when a medication is dispensed, it is dispensed with full knowledge and availability of that person's medication history.

NARRATIONIt's been two weeks and Jack McEnally has returned home with a new list of medications. He's not taking less, but some of the tablets did change.

Dr Maryanne DemasiSo just by changing the combination of drugs you felt better?

Jack McEnallyOh yeah, by 100 per cent.

Prof David Le CouteurOne of the joys of geriatric medicine is stopping medications and seeing people get better. We have phoenixes that rise from the ashes in geriatric medicine unlike any other specialty. People who come in that are very unwell and by the simple intervention of stopping medications we see people get better.

Agnes ThorburnI'm going home tomorrow and I'm not having any medication.

Dr Maryanne DemasiAre you pleased about that?

Agnes ThorburnOf course I am, I'm as happy as can be, and I'll be in the garden as soon as I get home.

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YOUR COMMENTS

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Ray Kleyn - 14 Aug 2010 10:27:30am

The MEDITATION CYCLE has been a concern for a long term consumer for the treatment of Epilepsy with many side effects plus impacts on quality of life experienced. I find it ironic that after any long term use of any drug that they will be changed irrespective of both positive or negative impacts & unseen side issues for now at least. Likewise dosage levels are almost always slowly increased of one type & then in conjunction with others. Indeed I suffered an allergic reaction to one commonly used & a medication I've taken on more than one cycle in my ongoing treatment cocktail. After many professional opinions a specialist can pinpoint my concern imediately but surprisingly another drug is added to negate the effect not a withdrawal of the drug causing the initial reaction.Also of recent times Depression has become part of my battles being a common one after long term & usage of some of the past epileptic drugs which many studies have shown. Again ironically I see a contradictory approach & many opinions by those treating me for these health complaints.It appears many common drugs are now used for mental health & very seldom for epilepsy which was their original purpose. Find it a concern that both the medications & specialists in either field are contradictory in the treatment & application of medications. Your story seemed to indicate my concerns were valid. Investigations on any clinical trials are proof too it seems as offers to participate are rejected when your already taking other tablets which poses a risk. What a surprise?

Jim - 13 Aug 2010 4:51:29pm

My late mother was prescribed Vioxx for arthritis. After a time on this drug she started having what the Dr called "mini strokes" where she would feel faint and disoriented. She seemed to suffer some memory loss after each of these episodes. Eventually the Dr took her off this drug and these horrible bouts stopped but not before some apparently irrevisible damage had been done

Brendan - 12 Aug 2010 8:20:33pm

My late wife was on a number of medications, and also chemotherapy. There were a few drugs that had the side effect of lowering her blood pressure which made her feel faint. Because she felt dizzy she stayed in bed for most of the time during her last six months. Just a few weeks before she died the cardiologist took her off one drug and reduced the dose of another. Within 24 hours the faintness disappeared, but unfortunately the time in bed had depleted her muscle mass, and she was still unsteady on her feet.Had the medication been adjusted earlier her quality of life may have been improved considerably.